Slide 1

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 2

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 3

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 4

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 5

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 6

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 7

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 8

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 9

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 10

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 11

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 12

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 13

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 14

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 15

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 16

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 17

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 18

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 19

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 20

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 21

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 22

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 23

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 24

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 25

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 26

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 27

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 28

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 29

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 30

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 31

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 32

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 33

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 34

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 35

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 36

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 37

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 38

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 39

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 40

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 41

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 42

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 43

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 44

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 45

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 46

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 47

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 48

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 49

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 50

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 51

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 52

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 53

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 54

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 55

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 56

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 57

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 58

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 59

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 60

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 61

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 62

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 63

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 64

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 65

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 66

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 67

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 68

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 69

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 70

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 71

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 72

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 73

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 74

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 75

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 76

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 77

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer


Slide 78

Anatomy of thorax

Landmarks – anterior view







Supresternal notch
Angle of Louis – cartilage
of the 2nd rib
Xifoid apendix
Subcostal angle
Thoracic lateral wall








Ribs 7, 8, 9, 10
Free ending 11, 12

Collar bone – acromion
Projection of diaphragm
(top ~ 5th rib)
Breast
Anterior axilary line

Bony structure

Muscles of anterior thoracic wall
significance in respiration

Landmarks
Posterior view



Processus sipnosum
Scapula:







Superior angle – C2
Inferior angle – C7
Ridge

Muscular prominences




Latissimus dorsi
Trapesius
Erectori spinae

Lines used for orientatiom




Median
Midd-clavicular line
Axillary line






Anterior
Middle
Posterior

Scapulary line
(through the inferior
angle) – armes being
close to the trunk

Superficial projections of
respiratory aparatus


Tracheea:




Lungs




Cricoid – angle of Louis
C6-C8-C10

Pleura


C8-C10-C12

Superficial projection of the heart
and great vessels








Aortic arch, brchiocephalic
trunk, inferior vena cava,
brahiocephalic veins are
projected behind the
manubrium
Internal thoracic vein – 1-3
cm lateral to the manubrium
Intercostal vessels
Heart projection
Pericardium

Mediastinum

Communications of the thoracic
cavity


Superior opening – base of the neck





T1 – C1 – manubrium
Tracheea, esofagus, great vessels from the neck

Inferior opening



T12 – costal margin xifoid apendix
Diafragm with openings ofering passage for



Esofagus, nerves vagus nerves
Aorta, inferior vena cava

The breast

Anatomy of the breast

Lymphatics of the breast

Autoexamination of the breast






Begin after onset of
hormonal sexual activity
Monthly – preferable
after menstruation
Inspection




Volume, position, profile

Palpation

Medical examination of the breast


History taking








Borths
Breast feeding + duration
Menstrual activity + changes
in the breast
Other lesions
Hormonal therapy

Palpation






Breast + breast tissue outside
“gland”
Nipple
Axillary lymph nodes
Skin
COMPULSURY BOTH
SIDES

Axillary lymphnodes


External thoracic (under the pectoralis
major)









Main collector

Brahial group
Inferior scapullary group - dorsal
Subclavicular – top of axxila
Central
Internal thoracic – not accesible

Imagistics


Ultrasound scan






Doppler effect for
vessels diposition

Mamography
Galactograpy

THORACIC TRAUMA

Common manifestations in thoracic
trauma


Pain







Relatively minor element
that triggers changes in
ventilation
Significant presence in any
thoracic trauma
Immobilization – not
applicable
Suppresses cough reflex
Finally generates airway
obstruction and hypoxia



Pneumotorax







Major deficit – loss of functional
pulmonary tissue
Complex mechanism

Airway obstruction
Acute respiratory failure
fearful complication







Tahipnea
Acute dispneea
Use of accessory respiratory
muscles
Cyanosis
Anxiety

Manifestations of
thoracic contusions

Contusions of soft tissue


Non-characterisctic
symptoms









Ecchymosed
Hematoma
Subcutaneous fluid
collections
Muscle tears

As a single lesion –
children (soft thorax)



Clinically – same as any
other locations

Sternal fractures


Mechanism





Type:






Direct impact
Acute flexion
transversal w/o movement of
fragments
Particular situation –
manubrio-sternal disjunction

Clinically




Pain
Deformity
Short sternumt with dimished
intercostal spaces

Costal fractures






Very frequent in
adulthood – 10%
More frequently in ribs
situated in the middle
unprotected area
Direct or indirect
mechanism




Direct – sharp bone
projected inside
Indirect – sharp bone
projected outside

Costal fractures


Clinically






Benign lesions
Pain
Diminished amplitude of
respiratory movements
Palpation – in the arrea of
fracture





Deformity
Osseous creptiations during
deep inspiration or cough

MAJOR risk


Lesion of pleura or lung



Direct lesions







Parietal pleura
Visceral pleura
Lungs
Intercostal vessels

Indirect lesion


Intercostal vessels

Common complications of
thoracic contusions and
wounds

Hemothorax


Blood acumulation in
the pleural space





Vascular lesions in the
intercostal space
(intercostal artery – very
important hemprrhage)
Pulmonary lesions
Mediastinal lesions



Clasification






Small: 300-500 ml occupies
the costo-diafragmatic angle
and has limited symptoms.
Medium: <1500ml reaches
the middle of the scapula
Large: >3000 ml





Hypoxia lung is compressed
Circulatory changes –
mediastinal shift
Hypovolemia

Hemothorax

Hemothorax


Clinical examination








Dull on percution
Respiratory sounds not
audible on the affected
side
Diminished amplitude of
respiratory movements

Chest X-Ray
Pleural puncture – will
show the nature of the
fluid (blood)

Typical hemothorax – secondary to
rib fractures
Massiv hemothorax

Small – in decubit the fluid extends
and shadows all the lung

Tension Hemothorax

Pneumothorax




Continuity between the
lung and pleural space –
during breathing in air
gets in the pleural space
Aer tends to migrate:




Through the fracture area
Through pleural ruptures
Through natural
communications of the
chest (mediastinum,
neck, etc)

Subcutaneous emphysema

Subcutaneous emphysema

Enclose pneumothorax


Mechanism





Pleural and pulmonary lesion
Wound – aer coming from
outside

Calsification




Exmanition:





Small / medium /massiv



Thoraci pain
Acute sensation of thoracic
constriction
Diminished amplitude of
respiratory movements.
Tympanic sound on percution
Diminished amplitude of
transmitted respiratory
sounds!!!!


IT MAY BE
TRANSMITTED FROM
THE OTHER SIDE

Enclosed pneumothorax

Open pneumothorax






Open wound in the
thoracic wall
Air freely enters and
exits during expiration
Air does not accumulate
and does not increase
pressure inside pleural
space

Tension pneumothorax








Wound in the parietal or
visceral pleura
Air enters the cavity
REPEATIDLY with each
inspiratory movement
The wound spontaneously
closes during expiratiosn
Accumulation of air in the
pleural space


Internal or external one-way
mechanism

Tension pneumothorax – physiologic
repercussions

Tension pneumothorax - symptoms


Acute onset







Hypoxia,
Respiratory distress,
Cyanosis
Agitation
Sensation of imminent death











Mediastinal compression (in
advanced stages)
Diminishes the functionality
of the “normal lung”
Decreases heart diastolic
filling (angulation of SVC and
IVC)
End point – Acute Respiratory
Failure and Acute Circulatory
Failure
Urgent decompression

Tension penumothorax

Flail chest






Complex thoracic
fractures –at least 3 ribs
each with 2 fractures
Typical mechanism is
by compression of
thorax
Associates complex
iternal organ trauma =
Multiple trauma patient



Classification






Ventral (including the
sternum) – frequent in
car accidents impact on
the steering wheel
Anterior and lateral
Lateral
Dorsal (unlikely – big
muscular structures)



According to mobility



Fix – at least temporarily
Mobil






Similar to fluid effusion
Part of thorax escapes the action of
respiratory muscles
Thorax no longer rigid
PARDOXICAL MOVEMENT

Flail chest

Flail chest


Complex respiratory
disfunction








Decreased pulmonary
capacity
Swinging air
Mediastinal shift

ARF and ACF
Surgical emergency

Flail chest

“Posttraumatic Soft Thorax”

Flail chest – internal stabilisation

Contusions of the rachis


Fracture-dislocation







Mechanism: rotation or hyperflexion
Pathology : dislocation of vertebra and spinal cord
compression
Clinically: neurologic defect, hematoma, subcutaneous
hemorrhage + unequal intervertebral spaces

Fracture of vertebral body




Mechanism: compression + flexion = vertebral surfaces not
parallel
Clinically: pain, musculare contraction, dorsal deformity of
the spine, usual without neurological signs

Other contusions










Pulmonary contusions
Diaphragmatic
contusions with
diaphragmatic hernia
Contusions of the heart
and pericardium
Trachea and bronchi
contusions
Esophageal contusions

Thoracic wounds
1.Non-penetrated
2. Penetrated
3. Perforant

Non-penetrating thoracic wounds








Sharp objects or low velocity
bullets
Bonny structures oppose
penetrating injuries
Ribs can change direction –
important when reconstructing
the trajectory
Symptoms



Wound
Hemorrhages from the intercostal
branch

Penetrating thoracic wounds



Lesion of the parietal pleura
Significant respiratory repercussions




Tension pneumothorax (external one-way vent)
Open pneumothorax
TRAUMATOPNEEA

Perforated
thoracic wounds






Lesion concerning
organs in the thoracic
cavity
Thoracic-abdominal
wounds – trajectory
should be defined
Symptoms and gravity
depend on individual
lesion

Trajectory reconstruction

Trajectory reconstruction

Thoracic-abdominal wounds

Diseases of the pleura

Pleural cavity





Virtual cavity
Parietal pleura
Visceral pleura
Minimal quantity of
liquid – very important
in respiratory movement

Pleural effusion
Spontaneous pneumothorax




Rupture of a emphysematous bulla

Common symptoms



Pain: “stabbing” variable in intensity
Respiratory symproms accordin to respiratory disfunction




Dispnoea – from insignificant to severe sensation of lack of air

Clinically




Immobile hemithorax
Hyper sonority on percussion, diminished amplitude of
transmitted vocal sounds and respiratory sounds
Chest X-Ray: collapsed lung

Pleural effusion


Hemothorax


Spontaneous bleeding








Tumors of the pleura
Hemothorax combined with pneumothorax
Idiopathic pleural hemorrhage

Clinical findings ~ any pleural effusions

Chylothoraxul



Lymph due to obstruction of major thoracic lymph
channel
Symptoms: fade clinic: pain, sensation of chest
compression, weight loss with quick recovery after
evacuation

Pleural effusions


Pleuritis



Acute or chronic infalmmation of pleura, w/o effusion
PURULENT PLEURITIS





Faza 1: diffuse pleuritis







Clinical signs of sepsis
Stabbing pain, cough, respiratory disfunction
Chest X-Ray non-concluding

Faza 2: localized pleuritis (according to gravity)





Rare primitive
Secondary to septic pathology affecting the lung

General signs fade away
Fluid collection on X-Ray + pleural effusion

Faza 3: chronic purulent pleuritis (inefficient treatment)




Clinical signs – minor or inexistent
Cough and low fever
CXR – empyema (fluid-air level - collection)

Pleural tumors


Primitive = MEZOTELIOMA








Rare
Involve parietal / visceral pleura
Frequent without symptoms or fant mediastinal
compression
CXR – abnormal opacity prompting thoracoscopic
examination + biopsy

Secondary


Metastatic pleural effusion

Surgical manifestation of
pulmonary diseases

Congenital lesions








Pulmonary agenesis
Pulmonary hypoplasia
Policystic hypoplasia
Giant lobar emphysema – largely inflated
hemothorax
Pulmonary sequestrum – area of the lung not
used in respiration – will transform cystic and
may be infected

Traumatic lesions
Pulmonary contusion
 Pathology – bleeding inside the parenchyma,
formation of hematoma, alveolar exudates=
TRAUMATIC PNEUMONIA
 Common signs




Non-productive cough
Expectoration with mucus or blood.
Associates frequent pleural effusion – aggravates
patients’ status

Pulmonary contusions






Mostly through aggressive trauma producing
compression of thorax with closed larynx
Gravity increased if in personal history are
diseases that decrese lung elasticity
Symptoms




Haemoptysis sometimes massive – may be lethal
Cough, stabbing pain, respiratory disfunction

Pulmoray contusion
blast syndrome


Particular form







Usual patients with multiple trauma
Shoch wave from a blast

Pathology: alveolar and capillary ruptures – lung is
transformed in a spongy non-functional tissue
Clinically:




Shock
Nasal and ear hemorrhages
Nonspecific respiratory changes + haemoptysis and
limitation of respiratory movements on the affected side

Blast syndrome

Wounds of the lungs and bronchi




Perforant wounds and
explosion (there should be
communication)
Common clinical signs








Cough
Dyspnoea
Respiratory failure

Haemoptysia
Subcutaneous emphysema
Pulmonary herniation in the
wound

Inflammatory lesions







Chronic obstructive
disease
Pulmonary abscess
Tuberculosis

In certain stages may
benefit from surgical
gestures

Parasitic lesions
Hydatid cyst


Second most frequent localization





Primary lesion
Secondary : hematogenous dissemination (exceptional) or
through the bronchial tract

Symptoms: number, localization, compresion, stage
pf development, complications



Mostly asymptomatic or nonspecific
Sign appear if large lesions develop



Proximity with pleura
Erosion in a bronchus

Pulmoary hydatid cyst


Uncomplicated


Symptoms






Non-productive cough
Stabbing pain
Intercostal neuralgic pain

Auscultation =non-significant. Diminishes sounds
may be perceived

Hydatid cyst


Complicated




Progressive opening in a
brinchus: mucus expectorate
= air-liquid level
Sudden opening







Dramatic – “like vomiting”
Risk of asphyxia
Major haemoptysis
Anaphylactic accidents

Opening in the pleura=
hidro- or hidropneumothorax

Lung cancer



Originates in the bronchi epithelium
Asymptomatic onset




Early stage:





Cough rezistent to any treatment
Thoracic pain + haemoptysis ~ pneumonia at onset

Advanced stages:







No significant signs, mostly in elderly and smokers

Cough and dyspnoea
Blody expectorate or mucus +blood
Pulmonary abscess

Diagnostic: CXR, CT, Bronchoscopy

Lung cancer

Lung cancer